| Background:Pelvic fractures are often caused by high-energy impacts.When combined with massive bleeding,the fatality rate of pelvic fractures can reach nearly 40%.The incidence of pelvic fractures has increased recently,and surgery is the preferred treatment for both pelvic and acetabular fractures.However,surgical options for pelvic fractures are a hot topic and a difficult problem in the field of Orthopedics.It is not rare for Pelvic ring fractures to be combined with contralateral anterior pelvic ring fractures.When considering the treatment of such pelvic fractures through an anterior approach,orthopedic surgeons often choose traditional anterior approaches combined with sacroiliac screws or double anterior incisions treatments.However,compared with a single incision,an increase in incision will prolong the time span of the operation and raise the risk of intraoperative iatrogenic injury.Few studies have been conducted on the use of a single open incision to treat these types of injuries.When applying the classical pararectus approach,the surgeon can reduce injury to the quadrilateral surface area under direct vision.Additionally,they can more adequately expose the pelvic entrance through this incision.The classical pararectus approach’s safety and feasibility have been widely recognized.The modified pararectus approach improves upon the classical approach by exposing a larger area of the pelvis while paying more attention to the protection of important structures.Currently,this modified approach has not been widely promoted.Purpose:To investigate the safety and feasibility of a single modified pararectus approach for posterior pelvic ring fracture and contralateral anterior ring fracture.Methods:Three fresh adult cadavers(two males and one female)were collected and dissected from one side of the pelvis using a modified pararectus approach.The surgical field was exposed from the ipsilateral anterior and posterior pelvic ring to the contralateral anterior ring so that operators could become familiar with the anatomic structures of this approach.Meanwhile,we simulated the operation during this process,exposed the structures of the contralateral superior ramus of pubis after treating the injury of the ipsilateral posterior ring of the pelvis,observed anatomic structures,and simulated the reduction of the contralateral anterior ring fracture.Attention should be paid to the range,location,and route of the contralateral corona mortis and iliac vessels.Finally,the relevant data and photographs were collected to evaluate the safety and efficacy of a single modified rectus abdominis approach for treating the posterior pelvic ring injury combined with contralateral anterior ring fracture.Results:The modified pararectus abdominis approach exposes structures medially to the ventral mesentery,such as Retzius’s space and the bladder,the contralateral edge of the S1 vertebral body posteriorly and medially,the L5 vertebral body cephalad,and the S1 foramina in the true pelvis.The same structures can be exposed laterally,as the traditional pararectus abdominis approach does.From this approach,the ipsilateral sacroiliac joint can be exposed,and the posterior ring fracture can be reduced and a plate can be placed on the edge of the true pelvic.Fracture and displacement can be treated after exposure of the ipsilateral sacroiliac joint.Additionally,compressed nerves and vessels can be relieved under direct vision.When dissecting contralaterally,the anterior ring fracture can be fixed by placing a plate behind the superior ramus of the pubic(from the iliopubic eminence to the pubic symphysis)after ligating the contralateral corona mortis.The total length of incision in cadavers was 7.84±0.18 cm,the average distance between the contralateral corona mortis and pubic symphysis was 57.07±1.04 mm,and the average distance between the contralateral iliopubic eminence and pubic symphysis was 67.43±0.87 mm.After ligating the contralateral corona mortis,a plate can be placed behind the contralateral superior ramus of the pubic to treat the fracture.The length of skin incisions in 11 patients was 7.99±1.40 cm,and the operation time was 171.82±76.92 min.According to Matta criteria,the approach showed excellent results in 3 cases,good results in 7 cases,fair results in 1 case,and poor results in 0 cases.The overall excellent rate was 90.91%.At the last follow-up,Majeed scoring showed excellent results in 6 cases,good results in 2 cases,fair results in 1 case,and poor results in 2 cases.The overall excellent rate was 72.73%.Conclusions:The modified rectus abdominis approach has significant advantages in minimally invasive and visual field for the treatment of pelvic posterior ring injury and contralateral anterior ring fracture.This approach is safe and effective,making it a feasible method to deal with anterior pelvic ring fractures.The approach can be used to treat injuries of the posterior ring and the contralateral anterior ring through single incision,which provides a significant minimally invasive advantage. |
